Get Authorization To Request And/or Release Member ... - Hmsa.com

Filling out the Authorization To Request And/or Release Member Information form is an important step in managing your health information securely. This guide provides clear instructions on how to complete the form accurately and effectively.

Follow the steps to successfully fill out the form.

1. Press the ‘Get Form’ button to access the form. This action brings up the document for you to complete.
2. In Part A, fill in all personal details including your last name, first name, middle initial, address, city, state, email, home phone number, cell phone number, birth date, and HMSA subscriber number, which you can find on your membership card.
3. In Part B, select the type of request you would like to make. There are three options: 1) request to have HMSA receive information, 2) request to have HMSA send information, or 3) revoke a previous authorization. Make sure to check only one box.
4. Next, in Part C, provide information about the authorized person or organization. Fill in their last name, first name, middle initial, address, city, state, ZIP code, organization name, and their telephone and fax numbers.
5. In Part D, specify the purpose of the information request or release. Indicate the reasons by checking appropriate boxes and provide additional information if needed. If sensitive information will be involved, ensure you initial the relevant sections.
6. In the same section, describe the specific information to be shared, including date ranges if applicable, and indicate when the authorization will expire.
7. In Part E, read through your individual rights carefully. It is crucial to understand the implications of your authorization before signing.
8. Finally, in Part F, sign and date the form. Ensure you print your name and provide your relationship to the member if you are signing on their behalf. Submit the completed form to the designated HMSA address or fax number provided.

Complete the Authorization To Request And/or Release Member Information form online today for secure management of your health information.